Friday 16 June 2017

HIV and TB in 2017: Time for Honesty and Transparency

A message to delegates at SA AIDS 2017

13 June 2017

We are a group of organisations and individuals concerned with the state of South Africa’s response to HIV and Tuberculosis (TB). We are worried that in a time when the HIV and TB response in South Africa should accelerate it may instead begin to unravel. The underlying reason for this danger is the ongoing and widespread dysfunction in the public healthcare system. It is also to do with a problem that infects and corrodes our wider body politic, corruption and capture of institutions that are meant to serve the public.

With more than 150 000 annual deaths from AIDS and TB, 270 000 new HIV infections and 450 000 new TB infections, we cannot afford a lacklustre response to an ongoing crisis that we have not yet brought under control.

Who weakened the NSP?


After months of supposed widespread consultation with civil society, the research community and other stakeholders, the National Strategic Plan (NSP) for HIV, TB and STIs 2017 – 2022 was released in May 2017.  The NSP is supposed to be the plan that brings us together and gives direction to our efforts. Unfortunately, the NSP, as it stands, fails to provide the much-needed direction and leadership we require. Important interventions civil society advocated for in the NSP have not been included or have been removed from the final draft. No explanations have been given for these various omissions or last-minute changes that weakened the NSP.

Some of our key concerns with the NSP include:
  1. Low targets for PrEP: The NSP’s extremely low targets for pre-exposure prophylaxis (PrEP) drastically weakens the possibility for HIV prevention among women and girls, sero-discordant couples, key populations and anyone who considers themselves at serious risk of HIV infection. Early drafts of the NSP made a strong case for the provision of PrEP as recommended by the WHO (a technical committee recommended a target of 500 000 as a start). Draft 2 of the NSP, which was the version that was presented to the SANAC Plenary and adopted by all sectors including government, agreed to a target of 1.4 million by 2022. In the final version of the NSP the PrEP target was reduced to a mere 85 000 people by2022.
  2. Gender-Based Violence, HIV and the absence of targets: In recent months, we have witnessed with horror the murder, rape and brutality meted out by men on women, girls and members of the LGBTQIA community. The continued extremely high rates of HIV infection amongst these groups are another form of this violence. We have argued that violence and HIV should be fought together, with bold, imaginative, resourced and visible campaigns. The complete absence of targets for key populations means that no one can be held accountable for implementation failures. This points to the NSP, in its current form, merely paying lip service to our communities without allocating resources or setting objectives and targets for the delivery of services.
  3. Ignoring community healthcare workers and human resources: The NSP fails to make any substantial commitments regarding community healthcare workers and human resource requirements more generally. In so doing, the NSP ignores the staff shortages plaguing the public healthcare sector in South Africa. Without serious engagement with this human resource crisis, it is highly unlikely that key NSP targets will be met.
  4. Dealing pragmatically with TB: The NSP provides no emergency plan for TB and especially drug-resistant TB this while rates of MDR and XDR-TB in South Africa are increasing alarmingly. While some promising commitments are made about finding more people with TB more quickly, no realistic indication is given as to how this will be done. 
  5. Failing sex workers: Despite progressive commitments in the South African National Sex Worker HIV Plan 2016-2019 on these issues, the final NSP was sanitised of provisions on the need for the decriminalisation of sex work and eliminating the police practice of using possession of condoms or lubricant as evidence of sex work and grounds for confiscation or arrest. This is despite clear international evidence and guidelines.  Similarly, the NSP does not make any specific reference to the far-reaching human rights abuses faced by sex workers or the need to recognise ‘sex work as work’ as stated by the Deputy President at the launch of the National Sex Workers HIV Plan in March 2016. Likewise, no attention is paid to the pressing issues of migration. 

Corruption and mismanagement in SANAC


While the NSP should provide the roadmap, the South African National AIDS Council (SANAC) is supposed to be the place where civil society and government can come together to jointly drive the programmes outlined in the NSP. 

Since SANAC was revived in 2007 many of us have put great energy into it and attempted to use the opportunities for consultation provided by SANAC. At times this consultative structure has functioned well. But in recent years consultations at SANAC have become further and further removed from our communities and the issues they face. In many cases civil society participation at SANAC has been reduced to irrelevance, with the current SANAC civil society leadership unable and unwilling to criticise any weaknesses of service delivery. This lacklustre approach is evident in the NSP.

In our view SANAC now faces a crisis of governance and legitimacy. The SANAC board of trustees have in recent months failed to respond with sufficient seriousness and transparency to the failure of SANAC civil society leaders to disclose financial conflicts of interest. The board has also failed to provide satisfactory explanations for funding approved for the organisation of a board member and various other questionable governance practices. In addition, the recent resignation of two board members (Phologkolo Ramothwala and Mthetho Tshemese) have not been explained. Questions remain over the process for appointing a CEO, which seems to have aimed at a preferred candidate (one who would be less independent and more willing to turn a blind eye to corruption) and the decision to appoint an interim CEO rather than extending the contract of the previous CEO. SANAC has been operating without a CEO for the last five months. 

SANAC is meant to be at the heart of social mobilisation around HIV and TB. To play this role its sectors must be deeply located in civil society. They are not. Not surprisingly therefore it has failed to conduct much-needed sector audits aimed at establishing representation and reach into real constituencies of people who claim to be civil society leaders. As a result, individuals with no constituencies in the real world can vote and be elected to positions of power. 

This has left SANAC open to capture by people intending to make money out of HIV and TB. This together with the previously mentioned concerns regarding governance at SANAC is deeply concerning given the billions of rands in aid that are channelled through SANAC structures.

We are disappointed that the SANAC Chairperson, Deputy President Cyril Ramaphosa, has not dealt with these allegations despite promising to do so in a letter to TAC. (See here for the original letters from TAC to the Deputy President in February and March 2017).

For these reasons, our various organisations will in the coming weeks be discussing the possibility of withdrawing from SANAC and stepping up our campaigns around HIV and TB through an independent and effective civil society co-ordinating structure. 

A new movement, new commitment, new energy


In conclusion, we reaffirm our commitment to work together amongst ourselves and other non-corrupt individuals and organisations for a revived response to HIV and TB, linked to a public healthcare system that provides quality services to all. We have set in motion this renewed commitment to work together at a meeting of partner organisations in Johannesburg on 8 June 2017. In future meetings, we will invite a much wider group of organisations and individuals. 

Together we will build a new movement for quality healthcare and the possibility of ending AIDS and TB in South Africa. We call on all delegates to the South African AIDS Conference and thousands of AIDS and TB activists and concerned persons to join the fight against opportunism whilst the task of responding to HIV and TB remains an enormous ongoing challenge that requires honesty and transparency about our successes and failures. 

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